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RAICATION AND CERTIFICATE FOR PAYMENT"' R1ADocument 10 01NER)I City Of St. Anthony PROJECT: ST. ANTHONY COt- MIITY CENTER APPLICATION NO: 12 DISTRIBUTION 10: 3381 Silver Lake Rd. MIER St. Anthony, MN 55418 PERIOD 70: 11/38/36 ARCHITECT CONTRACTOR FROM (COW)s GRADS CONSTRUCTION VIA (ARCHITECT's Williams/0'BriEn. Assoc. ARCHITECT'S 368 HIGHWAY 61 N. PROJECT NO: — HASTINGS, NN 55833 CONTRACT FOR: General Construction CONTRACT DATE: 18/24/95 Application is aade for PaynEnt, as shown below, in cannecticv CONTRACTOR'S APPLICATION FOR PAYMENT with the contract. Continuation Sheet is attached. -- -- - -----------------------------I ICHANGE ORDER SUMMARY I. ORIGINAL CONTRACT SUM ........................ $3j151 ,900.00 -------------------------1 2. Net Change by Change Orders .................. $ 119,114.00 (Change Orders approved in I ADDITIONS I DEDUCTIONS 1 3. CONTRACT SU)I TO DATE ..........................$3,271 ,014.00 1previous months by owner I - 1 14. TOTAL COMPLETED a STORED TO DATE ............. $2,878,419 .00 TOTAL 1 119,114.00 I 1Coluan G ) _ -------------------------------1 5. RETAINRGE: (Approved this Month I I I a. 5.88 % of CowpletEd Work $142,435 . 95 --- -- - 1 1 I (Column D+E ) lNumber IDate Approved I - I I b. 5.88 � of Stored Material :$ 1 ,485 .00 I I I I I (Column F) I I I I I- Total Retainage (Line 5ai5b) or I ---- --------------------------------I (Total in Column 1) ...................... $143,920.95 I TOTALS I ' 1 1 6. TOTAL EARNED LESS RETAINRGE .................. $,2, 734 ,498.05 I-- - --------------------I (Line 4 less Line 5 Total) (Net Change by Change Orders t 119,114 .00 1 7. LESS PREVIOUS CERTIFICATES FOR I— — - -------- -----------------I PAYMENT (Line 6 from prior Certificate) .. $2, 380,918. 50 The undersigned Contractor certifies that to the best of the Con- 8. CURRENT PAYMENT DUE .......................... $ 353, 579 . 55 tractor's knowledge, information, and belief the Work coserEd by 9. BALANCE TO FINISH, PLUS RETAI14AGE ............ $ 536, 515 .95 this Application for Payment has been completed in accordance with (Line 3 less Line 6) the Contract Documents, that all amounts have been paid by the Con- tractor for Work for which previous Certificates for Payment NEI-E issued and payments received from the Owner, and that current pay- - � IPAMELA M-SCHMITr sent shown herein is now due. '----'----- -- � gp1�,g1:,81�2000 CONTRACTOR:GRADS CONSTR TI O State- of: County of: 1�(10 Era Subscribed an or-n to before Be this S day ofd ,139 b /� S-n/ tJotary Public (EJc M. %C-V% By: Date: . Ily Commission expires',1bL,N 3t cam -------------------------------- -----------------'------=-------------- --- AMOUNT CERTIFIED ... :........................... R R C H I T E C 1'S C E R T I F I C A E F 0 R P A Y M E N T (Attach Explanation if amount cErtified diife,s fr-ea the amount ap P lied for.) In accordance with the Contract Documents, based on on-site obserr-a- ARCHITE s Williams rie sec. ations and the data comprising the above application, the Architect cos to the Owner that to the best of the Architect's know- By! Pate: 1 information, and belief the Work has progressed as indicated, s Certificate is not negotia le. The AP10LO;T CERTIFIED is the quality of the York is in accordance with the Contract; Documents ayable only to the Contractor named herein. Issuance, pay- and the Contractor is entitled to payment of the AMOU11f CERTIFIED. sent and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this contract.